HOW TO STOP QUAKESESE

With ectopic pregnancy, there are no unusual symptoms at the time of implantation. The corpus luteum
of the ovary continues to function as if the implantation were in the uterus. No menstrual flow occurs. A
woman may experience the nausea and vomiting of early pregnancy, and pregnancy test for human
chorionic gonadotrophin (hCG) will be positive.

At weeks 6 to 12 of pregnancy (2 to 8 weeks after a missed menstrual period), the zygote grows large
enough to rupture the slender uterine tube or the trophoblast cells break through the narrow base.
Tearing and destruction of the blood vessels in the tube result. The extent of the bleeding that occurs
depends on the number and size of the ruptured vessels. If implantation is in the interstitial portion of
the tube (where the tube joins the uterus), the rupture can cause severe intraperitoneal bleeding.
Fortunately, the incidence of tubal pregnancies is highest in the ampullar area (the distal third), where
the blood vessels are smaller and profuse hemorrhage is less likely. However, continued bleeding from
this area may in time result in a large amount of blood loss. Therefore, a ruptured ectopic pregnancy is
serious regardless of the site of implantation.

A woman usually expediencies a sharp, stabbing pain in one of her lower abdominal quadrants at the
time of the rupture, followed by scan vaginal spotting. With placental dislodgement, progesterone
secretion stops and the uterine decidua begins to slough, causing additional bleeding. The amount of
bleeding evident with a ruptured ectopic pregnancy often does not reveal the actual amount present,
however, because the products o conception from the ruptured tube and the accompanying blood may
be expelled into the pelvic cavity rather than into the uterus. Therefore, this blood does not reach the
vagina to become evident. If internal bleeding progresses to acute hemorrhage, a woman may
experience lightheadedness and rapid pulse, signs of shock.

When helping determine the possibility of an ectopic pregnancy, ask a woman whether she has pain or
vaginal bleeding. Any woman with sharp abdominal pain and vaginal spotting needs to be evaluated by
her health care provider to rule out the possibility of ectopic pregnancy. Occasionally, a woman will
move suddenly and move and pull one of her round ligaments, the anterior uterine supports. This can
cause a sharp, but momentarily and innocent, lower quadrant pain. However, it would be rare for this
phenomenon to be reported in connection with vaginal spotting.

By the time a woman with a ruptured ectopic pregnancy arrives at the hospital of physician’s office, she
may already be in severe shock, as evidenced by rapid, thready pulse, rapid respirations, and falling
blood pressure. Leukocytosis may be present, not from infection but from trauma. Temperature is
usually normal. A transvaginal sonogram will demonstrate the ruptured tube and blood collecting in the
peritoneum. Either a falling hCG or serum progesterone suggests that pregnancy has ended. If the
diagnosis of ectopic pregnancy is in doubt, a physician may insert a needle through the postvaginal
fornix into the cul-de-sac under sterile conditions to see whether blood can be aspirated. A laparoscopy
or culdoscopy can be used to visualize the uterine tube if the symptoms alone do not reveal a clear
picture of what has happened. However, sonography alone usually reveals a clear-cut diagnostic picture.

If a woman waits before seeking help, gradually her abdomen becomes rigid from peritoneal irritation.
Her umbilicus may develop a bluish tinge (Cullen’s Sign). A woman may have continuing extensive or dull
vaginal and abdominal pain; movement on the cervix on pelvic examination my cause excruciating pain.
There may be pain in her shoulders from blood in the peritoneal cavity causing irritation to the phrenic
nerve. A tender mass is usually palpable in Douglas’ cul-de-sac on vaginal examination.

Therapeutic Management

Although some ectopic pregnancies spontaneously end and then reabsorbed, requiring no treatment, it
is difficult to predict when this will happen, so when an ectopic pregnancy is revealed by an early
sonogram, some action is taken. If an ectopic pregnancy can be diagnosed before the tube has ruptured,
it can be treated medically by oral administration of methotrexate and leucovorin. Methotrexate, a folic
acid antagonist chemotherapeutic agent that attacks and destroys fast-growing cells. Because
trophoblast and zygote growth is rapid, the drug is drawn to the site of ectopic pregnancy. Women are
treated until a negative hCG titer is achieved. A hestrosalpingogram or sonogram is usually performed
after the chemotherapy to assess whether the tube is fully patent. Mifepristone, an abortifacient, is also
effective at causing sloughing of the tubal implantation site. The advantage of these therapies is that the
tube is left intact, with no surgical scarring that could cause second ectopic implantation.

If an ectopic pregnancy ruptures, it is an emergency situation. Keep in mind that the amount of blood
evident is a poor estimate of the actual blood loss. A blood sample needs to be drawn immediately for
hemoglobin level, tying, and cross-matching, and possibly hCG level for immediate pregnancy testing, if
pregnancy has not yet been confirmed. Intravenous fluid using a large-gauge catheter to restore
intravascular volume is begun. Blood then can be administered through this same line when matched.

The therapy for ruptured ectopic pregnancy is laparoscopy to ligate the bleeding vessels and to remove
or repair the damaged uterine tube. A rough suture line on the uterine tube may lead to another tubal
pregnancy, so either the tube will be removed or suturing on the tube is done with microsurgical
technique.

If a tube is removed, a woman is theoretically only 50% fertile, because every other month, when she
ovulates next to the removed tube, sperm cannot reach the ovum on that side. However, this is not
reliable contraceptive measure. Research in rabbits has shown that translocation of ova can occur –that
is, an ovum released from the right ovary can pass through the pelvic cavity to the opposite (left) uterine
tube and become fertilized and vice versa.(salphigictomy-removal of the fallopian tube.)
As with miscarriage, women with Rh-negative blood should receive Rh (D) immune globulin (RhIG) after
an ectopic pregnancy fro isoimmunization protection in future childbearing.

(See Appendix for illustrations)

II. OBJECTIVES

Generally, later than three weeks of orientation and exposure at the Perpetual Succour Hospital
–Station 3B, the proponents should contribute to the practice of managing ectopic pregnancy
cases in any clinical setting by utilizing the acceptable notions, skills, and outlooks that they will
be achieving from this study.

Specifically, later than three weeks, the proponents should:

1) devise a complete output on the specified client and condition through obtaining apt
orientation and clear instructions from the clinical instructor on how to devise the
study.

2) pool all data for printing and binding and finish the study before March 5, 2010, Friday,
the scheduled date of presentation.

3) submit the final hard and soft copies of the output to the clinical instructor.

4) gather as a group for brainstorming of ideas making use of individual researches about
the disease condition.

5) present the case study on the scheduled date.

6) defend the case study in front the panelists by answering the relevant questions thrown
by them.

7) identify and describe the signs and symptoms of ectopic pregnancy.

8) map out and explain the disease process of ectopic pregnancy.

9) identify and describe the various managements –especially nursing management –for
ectopic pregnancy.

10) gather again as a group for pointers and reactions from each member and from the
clinical instructor after the case presentation.